APS: Resection of Endometriosis / Endometrioma Please note that your information is saved on our server as you fill out this form. Procedure: Laparoscopic Resection of Endometriosis / EndometriomaForm Type* Formative Summative (Level 4 Assessment) Trainee / Assessor DetailsTrainee Name* TitleMr.Mrs.MissMs.Dr.Prof.A/Prof.Rev. Prefix First Last Level of training* 1st year 2nd year Date* DD slash MM slash YYYY Assessor Name* TitleMr.Mrs.MissMs.Dr.Prof.A/Prof.Rev. Prefix First Last Assessor Role* Training Supervisor Consultant Training Unit* Clinical Details*Number of times this procedure has been previously performed by trainee* 0 - 3 3 - 6 6 - 10 10+ Please rate the trainee in the domains below using the following scale: N = Not observed or not appropriate, D = Development required, S = Satisfactory standard for completion of this procedure (no prompting or intervention required) or score on the Global Rating ScaleCommunicates appropriately with patientQ1 - RatingN = Not observed or not appropriateD = Development requiredS = Satisfactory standardQ1 - CommentsCommunicates appropriately with assistant, anaesthetist and theatre staffQ2 - RatingN = Not observed or not appropriateD = Development requiredS = Satisfactory standardQ2 - CommentsDemonstrates appropriate pre-operative preparation: institution’s safety check, patient bladder managementQ3 - RatingN = Not observed or not appropriateD = Development requiredS = Satisfactory standardQ3 - CommentsDemonstrates appropriate operative preparation: patient preparation and positioning, patient bladder management, DVT prophylaxis, IV antibioticsQ4 - RatingN = Not observed or not appropriateD = Development requiredS = Satisfactory standardQ4 - CommentsEmploys appropriate primary entry techniqueQ5 - RatingN = Not observed or not appropriateD = Development requiredS = Satisfactory standardQ5 - CommentsEmploys appropriate secondary port insertionQ6 - RatingN = Not observed or not appropriateD = Development requiredS = Satisfactory standardQ6 - CommentsAppropriate vaginal, uterine, and/or rectal manipulationQ7 - RatingN = Not observed or not appropriateD = Development requiredS = Satisfactory standardQ7 - CommentsAppropriate intra-operative assessmentQ8 - RatingN = Not observed or not appropriateD = Development requiredS = Satisfactory standardQ8 - CommentsEmploys appropriate respect for tissueQ9 - RatingN = Not observed or not appropriateD = Development requiredS = Satisfactory standardQ9 - CommentsRespect for Tissue Global Rating ScaleDemonstrates appropriate time and motionQ10 - RatingN = Not observed or not appropriateD = Development requiredS = Satisfactory standardQ10 - CommentsTime and Motion Global Rating ScaleEmploys appropriate instrument handlingQ11 - RatingN = Not observed or not appropriateD = Development requiredS = Satisfactory standardQ11 - CommentsInstrument Handling Global Rating ScaleDemonstrates appropriate knowledge of instrumentsQ12 - RatingN = Not observed or not appropriateD = Development requiredS = Satisfactory standardQ12 - CommentsKnowledge of Instruments Global Rating ScaleDemonstrates appropriate use of assistantsQ13 - RatingN = Not observed or not appropriateD = Development requiredS = Satisfactory standardQ13 - CommentsUse of Assistants Global Rating ScaleDemonstrates appropriate flow of operation and forward planningQ14 - RatingN = Not observed or not appropriateD = Development requiredS = Satisfactory standardQ14 - CommentsFlow of Operation and Forward Planning Global Rating ScaleDemonstrates appropriate knowledge of specific procedureQ15 - RatingN = Not observed or not appropriateD = Development requiredS = Satisfactory standardQ15 - CommentsKnowledge of Specific Procedure Global Rating ScaleCorrectly identifies anatomical structures and surgical spacesQ16 - RatingN = Not observed or not appropriateD = Development requiredS = Satisfactory standardQ16 - CommentsRecognizes own limitationsQ17 - RatingN = Not observed or not appropriateD = Development requiredS = Satisfactory standardQ17 - CommentsManages any complications effectively & efficientlyQ18 - RatingN = Not observed or not appropriateD = Development requiredS = Satisfactory standardQ18 - CommentsAppropriately completes procedure, closes incisionsQ19 - RatingN = Not observed or not appropriateD = Development requiredS = Satisfactory standardQ19 - CommentsDevises appropriate post-operative management planQ20 - RatingN = Not observed or not appropriateD = Development requiredS = Satisfactory standardQ20 - CommentsVerbal Feedback is a mandatory component of this assessment.Areas of StrengthPlease use this space to record areas of strength which were highlighted during discussion with the trainee.Suggestions for DevelopmentPlease use this space to record suggestions for development which were highlighted during discussion with the trainee.After summarising the discussion with the trainee in the boxes above, please complete the level at which the procedure was performed on this occasion. Please note: For a SUMMATIVE ASSESSMENT, the trainee must be assessed as Level 4 "Competent to perform the procedure unsupervised or independently".Assessment Level* Level 0: Insufficient evidence observed to support a summary judgement Level 1: Unable to perform the procedure under supervision Level 2: Able to perform the procedure under supervision Level 3: Able to perform the procedure with minimum supervision (needed occasional help) Level 4: Competent to perform the procedure, including complications without complications Assessor's SignatureAssessor's Name* First Last Candidate's SignatureCandidate's Name* First Last Confirmation Email* You will receive an automated confirmation email once this form has been submitted.EmailThis field is for validation purposes and should be left unchanged. Δ